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Radiology Coding Alert

Shore Up Your Zevalin Therapy Claims With 78804 or 79403

Understand the different codes for diagnostic and therapeutic procedures When your radiation oncologist or nuclear medicine specialist uses the anti-cancer drug Zevalin (ibritumomab tiuxetan) for radiopharmaceutical treatments, you should choose either 78804 or CPT 79403 based on the nature of the service: either diagnostic or therapeutic. Typically, physicians use Zevalin along with the drug RituXan (J9310) as a single course of treatment on patients with non-Hodgkin's lymphoma (for example, 202.8x, Other lymphomas) who have not responded to conventional chemotherapy or have relapsed. 1. Use CPT 78804 for Diagnostic Services Because Medicare hasn't issued national guidelines on Zevalin therapy, you should follow your local carrier's specific coding policies. But typically, you should use 78804 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; whole body, requiring two or more days imaging) if the physician localizes a tumor or distributes Zevalin throughout the whole body. The study generally requires more than two days of imaging.

To report the diagnostic dose of Zevalin in an office or freestanding center, you should use A9522 (Supply of radiopharmaceutical diagnostic imaging agent, indium-111 ibritumomab tiuxetan, per mci) for one unit of service. Tip: Code 78804 usually represents the physician's diagnostic services, radiation oncology coding experts say. Even if the radiation oncologist performs multiple days of radiopharmaceutical testing, report 78804 only once.

Here's why: According to the Mutual of Omaha local coverage determination, "The procedure encompasses the administration of Indium-labeled Zevalin and whole body radionuclide scanning 2-24 hours and 48-72 hours after the administration of Zevalin. ... The purpose of the scanning is to ensure that the biodistribution of Zevalin is normal, thus decreasing the risk of toxic effects from administration of a therapeutic dose of Zevalin." Document Should Include Interpretation,Report In rare cases, patients may also require a third set of images at 90-120 hours. After providing review and oversight during the entire study, the physician personally supervises a slow infusion of the monoclonal antibody, watching for potential reactions. The physician should also make sure images are free of motion and artifacts.

After the second or third set of images, the physician will compare the images, which is why you report only one code. Your documentation should include the complete interpretation and report, along with information about who performed the injections and how long it took. Many Medicare carriers, such as Group Health NY, maintain that you shouldn't report therapeutic radiophar-maceutical administration separately, because the carrier includes the service in the overall procedure codes. Typically, you can expect a Medicare insurer to pay about $240 for 78804. 2. Monoclonal Antibody Therapy Requires 79403 When the radiation oncologist delivers Zevalin in an office or freestanding center through monoclonal antibody therapy to the non-Hodgkin's lymphoma patient, you should [...]

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